Pelvic Exams On Anesthetized Women Without Consent: A Troubling And Outdated Practice

Are doctors-in-training and medical students still performing pelvic exams on anesthetized women without their consent?

I was surprised to learn this was still going on today. I would have expected it in teaching hospitals during the 1950s — but not in 2018.

But in a recent excellent article by Phoebe Friesen in the journal Bioethics, she notes that “that the practice is alive and well” in many US and UK medical schools. It’s difficult to know exactly how often this is happening. Most medical school faculty and students don’t talk about it publicly, and affected patients are (by definition) unaware this is happening.

However, Friesen notes that a survey “at the University of Oklahoma in 2005 found that a large majority of medical students had given pelvic exams to gynecologic surgery patients who were under anesthesia, and that in nearly three quarters of these cases the women had not consented to the exam.” Similarly, a UK survey “reported that at least 24% of intimate examinations they performed on anesthetized patients occurred without any consent and that ‘on many occasions, more than one student examined the same patient’.”

Of course, there are medically appropriate reasons to perform a pelvic exam on an unconscious woman as part of a legitimate treatment plan, for instance to plan placement of a surgical instrument before removing a gynecological tumor. And this type of exam is covered by the standard informed consent process prior to surgery.

But the more troubling cases involves situations where a patient is unconscious, then the senior attending surgeon at the teaching hospital invites medical students and trainees to perform a pelvic exam not for therapeutic purposes, but for “practice” purposes — without obtaining the patient’s consent beforehand. As bioethicist Arthur Caplan describes, “Sometimes, more than one student will practice the exam, with many sets of gloved fingers in the patient’s vagina without their knowledge.”

When I mentioned this to some of my non-medical friends (both male and female), their dominant reactions were horror and anger. One friend pointedly asked, “How is that not rape?”

Friesen also discusses some attempted justifications for this practice. One common argument is that, “it’s good for society” — the practice will make the trainee a better doctor, which will benefit future patients (even if it doesn’t benefit the current patient being examined).

Another common argument is that “it’s no big deal” — it’s a relatively minor act that causes no harm.

A third attempted justification is that patients coming to a teaching hospital implicitly allow their bodies to be used for education purposes, and that no further explicit consent for such a pelvic exam is necessary.

Friesen quoted two representative examples of opinions for and against this practice from an online discussion forum, StudentDoctor.net.

It’s suprising [sic] how worked up some people get over the issue. You will be naked on a brightly lit table for all to see. A medical student will put a tube into your bladder. We’re about to flay your belly open and remove your uterus and ovaries. But to do a pelvic exam! What a violation!

If you get into this habit of being deathly afraid of the patient’s feelings about an internal exam you will never learn how. I’m not saying that you should be a jerk about it, but you owe it to your future patients to get some idea of what stuff feels like.

I am cringing a little at this thread. As a female student not yet in the medical field, I am disturbed to hear that by consenting to surgery, I risk having someone literally in my vagina without consent for purposes that benefit only the providers, and not me. Are patients really viewed as a teaching tool rather than a human being? That I will be splayed and sliced during the procedure doesn’t mean that additional indignities are acceptable.

It’s still my vagina, even if I am naked and unconscious. I didn’t lend it to anyone to practice techniques.

Surveys of patients support the second viewpoint expressed. Friesen notes that “the vast majority (72–100%) of women say they expect to be specifically consented for an educational pelvic exam performed while they are under anesthesia” and that many women “said they would feel ‘physically assaulted’ if not consented.”

Illustration of a doctor performing a pelvic exam, from an 1825 medical textbook.

So why don’t teaching hospitals make it a standard practice to obtain explicit informed consent ahead of time? My suspicion is that many faculty members view it as an unnecessary hassle — and that if they asked for consent, then too many women would say “no.”

However, this turns the principle of consent on its head. If there is a physically invasive procedure (e.g., a pelvic exam while unconscious) that hospitals and doctors know a significant fraction of patients would not agree to if given a choice, then it’s all the more important to ask them first. Deliberately choosing not to ask due to fear of a “no” answer and instead performing the procedure anyways violates the very concepts of consent, patient autonomy, and individual rights.

(Men should also realize that this issue is not limited to female patients. Unconscious male patients can sometimes be subjected to rectal and prostate exams by medical students without their consent.)

Fortunately, not all teaching hospitals engage in this practice. Some university hospitals use willing volunteers to teach medical students how to perform pelvic exams, under the close supervision of faculty members. This was how I learned when I was a medical student at the University of Michigan.

So what can patients in a teaching hospital do to protect themselves? I have three suggestions:

1) Before undergoing anesthesia for any kind of surgery, specifically state that you don’t agree to a pelvic exam while unconscious. State this preference to more than one person (for instance to both the doctors and the nursing staff). Make sure your preference is recorded in writing in your informed consent form.

2) Contact the hospital ombudsman before the surgery. Ask them if they are aware of this practice occurring in this hospital, and specifically record your preference with their office before your surgery. The ombudsman’s job is to be the patient advocate relating to any concerns or complaints about their care. Take advantage of them as a resource.

3) Urge your state legislators to support legislation outlawing this practice. The practice of performing pelvic exams on unconscious patients without consent is currently illegal in four states (Hawaii, California, Illinois, and Virginia). I would imagine that many lawmakers in the other 46 states would gladly sponsor a bill protecting patients’ rights in this manner.

One of the bedrock principles of Western medicine is a respect for a patient’s bodily autonomy. Respecting patients’ autonomy becomes all the more important when they are unconscious and vulnerable. I hope this article sheds some light on a practice that needs to change and helps patients better protect themselves.